Provider Demographics
NPI:1629245634
Name:QUALLS, BENITA K (PA)
Entity type:Individual
Prefix:MRS
First Name:BENITA
Middle Name:K
Last Name:QUALLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:BENITA
Other - Middle Name:K
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1407 W BADDOUR PKWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-444-6203
Mailing Address - Fax:615-444-6252
Practice Address - Street 1:1407 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-444-6203
Practice Address - Fax:615-444-6252
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3323092OtherUHC
TN1523861Medicaid
TN185OtherPHYSICIAN ASSISTANT LICENSE
TN4298144OtherBCBS
TN103I971707Medicare PIN